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Independent Serious Incident Thematic Review published

11 March 2015

A Thematic Review was commissioned by Wendy Wallace, CEO of Camden and Islington NHS Foundation Trust (C&I) following 19 serious incidents involving patients of the Trust in a seven month period dating from November 2013 to end of May 2014.

The review was commissioned to determine whether there were any service related themes or issues associated with the incidents which could be identified and whether the incidents taken as a whole formed a cluster. It would be considered a cluster if the deaths were found to be linked in some way or shared the same cause. The review looked at whether similar events occurred in proximity to one another, either geographically or temporally, and whether there was any causative or contributory relationship.

The review concluded that the presence of a cluster is not suggested. In addition, the independent panel also concluded that the change in C&I's community provision and reduction in its numbers of beds had not contributed to these   incidents.

Themes were identified in the review, which have formed valuable findings and conclusions to improve safety and the quality of care, and following its approval by the commissioners' Clinical Quality Review Group and the Trust Board, a full action plan is being drawn up to address the recommendations.

You are able to download the the full report and a document outlining the context and key findings from the buttons on the right.

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